UNIVERSITY PROCEDURE
Checking and Evaluation of Compliance
Document No
CU/11/CEC/Pr/1.0
Area Applicable
All Cardiff University
Review Year
2014
Document History
Author(s)
Revision
Number
.01
Date
Katrina Henderson
Date
Amendment
Name
October 2011
Approved by
Checking and Evaluation of Compliance Procedure
I.
PURPOSE:
To ensure that the University has a method for checking its Safety, Health and
Environmental Performance. It also ensures that the University has a method
for periodically evaluating compliance with applicable legal requirements and
other requirements to which it subscribes.
II.
SCOPE :
This procedure applies to the periodic checking of measurement, monitoring
and evaluation of the University’s Safety, Health and Environmental
performance
The purpose of this procedure is to describe the different checking areas and
where appropriate signpost to additional procedures which are in place. It also
applies to the periodic evaluation of the regulatory compliance of Cardiff
University with relevant safety, health and environmental legal and other
requirements applicable to its operations.
III.
RESPONSIBILITY:
ESTAT is responsible for the evaluation of compliance of statutory obligations
that it manages on behalf of the University. A register of the obligations can be
accessed through ESTAT Compliance Officer
OSHEU is responsible for evaluating compliance with legal and other obligations
held within, and relevant to, each School and Directorate and for reporting the
results to SHEA
Heads of Schools / Directorates are responsible for the review of compliance
against legal and other obligations relevant to them and acting on the findings.
Safety, Health and Environmental Committee receives reports from OSHEU on a
biannual basis including the results of audits and evaluation of compliance.
Council receive briefings from the University Safety, Health and Environment
Committee via the Governance Committee.
University Management Board are advisory to the Vice Chancellor and receive
guidance and performance reports from OSHEU on a quarterly basis including
the results of audits and evaluation of compliance.
IV.
PROCEDURE:
Periodic compliance with identified legal and regulatory requirements will be
reviewed by OSHEU and changes reported to the DSO/Eco Champion meetings
every 6 months, checks will also be carried out within the internal audit
programme. This will include specific aspects including waste legislation, listed
buildings, planning conditions etc. Evaluation of compliance against specific
operational controls will be checked including monitoring and sampling results.
Subject
Brief Description
Lead
Additional
Procedure
Performance
measurement
and monitoring
Reports through SHEA
against SHE Objectives and
targets.
OSHEU/ESTAT
Management
Review
Incident
Reporting
Internal audit to review
School/Directorate
Objectives and Targets
Internal audit
Occupational
Hygiene
Workplace monitoring of
local environment
(Substance/Noise/Temperat
ure)
Need for monitoring
identified through Risk
Assessment
(Schools/Directorates)
OSHEU
Procedure
Duty of care
audits
Biannual audits carried out
on hazardous waste
contractors checking against
Statutory, Licence and
Service provision
OSHEU
Link to
responsibility
table
Internal audits
To include Management
System audits carried out by
OSHEU. Subject audits
carried out by Joint Internal
Audit
OSHEU/JIA
Internal audit
Procedure
Workplace
inspections
Schools/Directorates
required to carry out
workplace inspections as set
out in the Monitoring Policy.
Schools/Directorates
Monitoring Policy
External audits
To include BV 6 monthly
audits of the Management
System/ Specialist audits
carried out by
HSE/Environment
Agency/other specialist
areas.
Coordinated by
OSHEU/ESTAT
Subject
Brief Description
Lead
Additional
Procedure
Control of
records
Ensure all Statutory records
are maintained in an
appropriate manner.
GOVRN/OSHEU/Schools/ Link to
Procedure
Directorates
Nonconformity,
corrective action
and preventative
action
The procedure defines
responsibility and authority for
ensuring that nonconformances are addressed
and appropriate corrective and
preventative action is taken in
line with the University’s
safety, health and
environmental management
system
OSHEU/SHEA/Schools
Evaluation of
compliance
ESTAT is responsible for the
evaluation of compliance of
statutory obligations that it
manages on behalf of the
University. A register of the
obligations can be accessed
through ESTAT Compliance
Officer
OSHEU/ESTAT
Corrective
Action Procedure
OSHEU is responsible for
evaluating compliance with
legal and other obligations
held within, and relevant to,
each School and Directorate
and for reporting the results
to senior management.
Incident
investigation
The investigation covers
underlying causes, outcomes
and potential outcomes as well
as the consequences attributed
to what happened. The
purpose of the investigation is
to limit and reduce the
likelihood of reoccurrence.
Investigation
undertaken by
School/Directorate
where incident
originated. For serious
incidents OSHEU
involvement
Incident
Reporting Policy
Evaluation of compliance
Workplace
inspections.
Procedure no:
Internal audit
(OSHEU)
Procedure no:
Duty of care
audit
Evaluation
of
compliance
Internal audit
(ESTAT)
Procedure no:
Internal audit
team
External Audit